Payment Integrity Analyst II – Data Mining

Role Overview

• Supports the Data Mining (DM) program by independently investigating moderate-to-complex payment errors resulting from incorrect processing of payment policies, contract terms, billing, and/or coding to prevent and recover improper claim payments.
• Performs hands-on casework in a high-volume environment, including investigation, documentation, and system updates, while applying advanced analytical skills to interpret claims and reimbursement data, identify trends and false positives, and contribute to concept development and process improvements that enhance accuracy and operational performance within the DM program.
• Operates with increased autonomy, applying judgment to resolve non-routine scenarios, and contributes to improving workflows, logic, and data quality, while collaborating cross-functionally to support scalable payment integrity outcomes.
• Review, prioritize, and independently work assigned DM leads (automated and manual), including moderate-to-complex and high-dollar cases, to determine verification steps and next actions.
• Investigate and validate payment terms (Inpatient, Outpatient, Professional, Ancillary) using internal systems, payer portals, contracts, and other approved data sources.
• Analyze claim inventory from identification to resolution.
• Develop concept overviews and analysis.
• Compile sample claims and supporting documentation for Client review and approval.
• Maintain a library that includes instructions for validating specific audit concepts.
• Create clear, detailed, and accurate case notes that capture verification steps, evidence, and outcomes in internal tools to support audits and downstream recovery/reprocessing.

Requirements

• Minimum of five (5) years of combined experience in healthcare, such as prior work in health insurance, claims processing or adjudication, overpayment, fraud, and/or waste and abuse detection
• Minimum of three (3) years of experience auditing medical claims or performing payment integrity casework, including independent handling of moderately complex scenarios.
• Minimum of three (3) years of experience performing data analysis with large datasets.
• Working knowledge of medical billing codes including but not limited to CPT, ICD-10-PCS, ICD-10-CM, HCPCS, and NDC, as well as an understanding of medical terminology, and prospective payment systems including DRG, OPPS, and MIPS.
• Bachelor's degree in business or healthcare/related field.
• Demonstrated ability to analyze and interpret payment policies, contract terms, and reimbursement methodologies across professional and facility claims.
• Excellent verbal and written communication skills.
• Excellent documentation accuracy and attention to detail.
• Ability to work within established productivity and quality metrics while prioritizing workload with minimal supervision.
• Strong problem-solving skills with the ability to resolve conflicting or incomplete information and escalate appropriately.
• Ability to maintain confidentiality and comply with HIPAA and data security standards.
• Experience supporting audit concept development, validation, or rule refinement within a data mining or payment integrity program.
• Demonstrated experience contributing to process improvement initiatives with measurable impact on accuracy, turnaround time, or false positives.
• Familiarity with contract terms, payment policies, and root cause analysis for payment errors.
• Working knowledge of claim adjudication workflows and payment rules.
• Experience building queries/filters or using reporting tools; basic SQL or query-tool proficiency preferred.
• Experience in high-volume, SLA-driven operations environments.
• Ability to identify trends and translate findings into actionable operational or analytical improvements.
• Creative thinker with an entrepreneurial spirit.

Tech Stack

• SQL